Herd Immunity

Can the social contract be protected from a measles outbreak?

“We whose Names are underwritten . . . Covenant and Combine our selves together into a Civil Body Politick, for our better ordering and preservation, and furtherance of the ends aforesaid . . . unto which we promise all due submission and obedience.”
—Compact signed by passengers aboard the Mayflower before landing at Plymouth, November 21, 1620.

In the fall of 1713, measles struck the city of Boston, where Cotton Mather, a Puritan theologian and pastor, lived with his pregnant wife and numerous children. Within a month, his wife, their twin newborn babies, another child, and their maidservant had all died. On November 12, Mather wrote in his journal, “The epidemical Malady began upon this Town, is like to pass thro’ the Countrey. . . . it [might] be a service unto the public, to insert in the News-paper, a brief Direction for the managing of the sick. I will advise with a Physician or two.” On November 21, he wrote, “Lord I am oppressed; undertake for me!” On November 23, he wrote, “My poor Family is now left without any Infant in it, or any under seven Years of Age.”

Eight years later, when an explosive smallpox epidemic threatened Boston’s population of eleven thousand, Mather became an outspoken advocate for a new prophylactic against the virus: inoculation. Dr. William Douglass, one of the few doctors in town with a medical degree, rallied others to oppose Mather, claiming that the method was untested (which was true, at least in the new colony) and that it jeopardized the lives of all those who received it. In young Boston, the fight over inoculation tore at epidemic-addled nerves. In November 1721, a bomb was thrown through Mather’s window. A letter attached to it read, “Cotton Mather, you dog, dam you! I’ll inoculate you with this; with a pox to you.”

Douglass won out, quashing Mather’s plans for a systematic inoculation of the town’s population. Eight hundred and forty-four people died of the virus, accounting for 75 percent of all deaths in Boston that year. The unexploded bomb on Mather’s floorboards disabuses those of us living in 2019 of the impression—generated over the past two years by endless news stories about the current global measles outbreak—that inoculation controversies are a novel feature of our present hyper-mediated, hyper-politicized time.

Measles was considered to be eliminated in the United States in 2000. Still, the virus has regained extraordinary ground—and claimed an increasing number of lives—in recent years. Seven hundred and four cases were reported in the United States in the first four months of 2019, according to the Centers for Disease Control and Prevention. The count reached 1,077 by mid-June, occurring in twenty-eight states. More than six hundred cases have occurred in New York City alone since September of 2018.

In June, the CDC issued a warning to travelers planning to leave the country, by which point outbreaks were occurring in all the places you’d expect, countries beset by depressed economies, poor public health management, war, or extreme poverty, including Ethiopia, Madagascar, Kyrgyzstan, the Democratic Republic of Congo, the Philippines, Sudan, and Georgia (not the U.S. state, although cases have been reported there as well). But also, cases were appearing in countries where entrenched vaccination systems existed and where measles had been thought largely a disease of the past: Belgium, France, Germany, and Italy.

The grand cause for these infections—and for the 300 percent growth of reported measles cases around the world in the first quarter of the year over the same quarter the previous year—is precisely the absence of what Cotton Mather proposed for 1721-era Boston: systematic vaccination of the population. The more interesting question, beyond simple international vaccination logistics, is: What ideological and historical shifts have allowed the reemergence of a disease once believed to be under controlled decline?

The tragic factors preventing the international vaccination of children and susceptible adults are not only a glimpse into dozens of subcultures, their history, politics, and basic vulnerabilities. As climate change increases displacement and viruses thought long gone reappear (“Climate change could bring the bubonic plague back to Los Angeles,” read a recent headline in the Los Angeles Times), a dissection of the current epidemic’s course around the globe gives us a glimpse into our uncanny, dystopian future. Just as important, however, the current measles epidemic provides us with a master class on the catastrophic breakdown in our understanding of what we might call the social contract.

Hotzoned

More than one hundred thousand people worldwide died of measles in 2017, nearly three hundred a day. Men, women, and children—but mostly children—first experienced a fever of about 103 degrees or higher. They had a cough, a runny nose, and swollen eyes. They had no energy or appetite.

A few days after the fever, a rash appeared, first on their faces, then spreading to their torso and limbs. In the United Kingdom, one in twelve developed ear infection or diarrhea. As many as one out of sixteen developed pneumonia, particularly those with already compromised health: those who were pregnant, in chemotherapy, recovering from an organ transplant, suffering from an autoimmune disease, the elderly, the very young. One out of every one to two thousand developed encephalitis, the swelling of the brain. According to the CDC, one to three out of every one thousand children who contract measles die of respiratory and neurologic complications.

For the survival of the state, the body politic must be protected.

Measles is more contagious than Ebola, HIV, or the common cold. The virus lives in the nose and throat of the patient and when expelled with a breath or a cough, it can linger in the air or on surfaces for up to two hours. Measles is so contagious that, according to the CDC, up to 90 percent of the people close to a patient will become infected unless they are immune. Patients are infectious four days before the first symptoms appear until four days after. In June of this year, Jason Prystowsky, a doctor in Santa Barbara, California—a state where strict laws preventing vaccination exemptions were passed after a Disneyland outbreak in 2014, and where additional legislation is constantly percolating—wrote a brief and earnest, even pleading, article titled, “Measles, Healthy Children and a Community’s Social Contract.” Prystowsky wrote, “Measles is a virus. Antibiotics do not work. There is no cure. No quick fix. Children with measles suffer, and it can be hard to watch.”

Evasion of the Body Snatchers

If you’ve heard of Cotton Mather, it’s probably because of the somewhat unfair connection history has given him to the Salem witch trials of 1692-1693. While Mather clearly believed in punishing evil spirits (Mather’s study, Memorable Providences, Relating to Witchcrafts and Possessions, was published in 1689), he did not think the accused and convicted should be punished with death.

Less than a generation before Mather was examining bodily possession in Puritan New England, John Locke and Thomas Hobbes were across the pond writing about self-possession, already laying groundwork for the types of inoculation (the defense of bodies and the body politic) Mather and his colleagues in England would soon begin to advocate.

The Habeas Corpus Act (literally, “you shall have the body”) of 1679 wrested our souls from the ownership of the King (who, people had been taught, enacted the will of God through divine right) and gave us our bodies as property. We were, in the eyes of the law, self-possessed. As Ed Cohen writes in A Body Worth Defending, “When natural law construes the body as a human possession, that is, as personal property, it mandates bodily defense as a possessive imperative that politically safeguards the person as a person.”

What then would be the role of the state in decisions affecting those individual bodies? Within a hundred years, Gerard van Swieten, a Dutch physician and skeptic on inoculation who treated the Austrian Empress Maria Theresa, nonetheless provided a theoretical basis for “population as a state’s vital asset,” as Cohen puts it. In van Swieten’s work, Cohen wrote, the “argument for or against inoculation turns on the collective or numerical effects it produces rather than on the particular outcomes of singular examples.”

Throughout the century, the obligations (and interests) of the state became intertwined with the health and well-being of the population. For the survival of the state, the body politic must be protected. But, as social contract theory explains, in exchange for this protection, individuals must be willing to give up certain rights.

When Massachusetts passed the nation’s first law requiring the vaccination of children against smallpox in 1855, outrage was quick to follow. Boston’s early anti-vaxxers produced pamphleteering screeds claiming, “Vaccination Is the Curse of Childhood,” and declaring their children “unfit for vaccination.” But when the Supreme Court decided its first case on mandatory vaccination in 1905, Jacobson v. Massachusetts, Justice John Marshall Harlan confirmed that the “common good” justified sacrifice of some personal liberties. Subsequent cases in 1922 and 1944 upheld this jurisprudence.

Rosh Hashanah in Uman

That had little influence, of course, on other countries. In 1990, measles killed 872,000 people around the world. A decade later, a coalition of world health bodies teamed up with benevolent global citizens and philanthropists like Ted Turner and Bill and Melinda Gates and “declared war on measles,” as Donald G. McNeil Jr. characterized the massive effort for the New York Times last April. Billions of dollars were spent on the training of medical practitioners, on distribution and supplies, and on refrigerated storage facilities in remote places. The effort was astoundingly effective. Deaths from measles dropped nearly 80 percent between 2000 and 2016.

By 2017, global cases were again on the rise. The cause? Poverty.

But by 2017, global cases were again on the rise. The cause? Poverty. War-torn countries, poor countries, couldn’t keep up the annual vaccination routines. Pockets of the unvaccinated grew and, inevitably, the virus found new pools of victims. McNeil’s devastating tally for poverty-burdened, conflict-riddled countries around the globe at the time read, “Madagascar has seen 66,000 cases of measles, with more than 900 dead. India has had 63,000 cases; Pakistan, 31,000; Yemen, 12,000; Brazil, 10,000; and Venezuela, 5,700.”

Wealthy world powers may have their own dysfunctional causes for recent measles outbreaks, but clearly their efforts toward global peacemaking and economic equality cannot be claimed as a distracting excuse.

Because of international travel, several outbreaks over the past two years shared a far-flung source, the Ukraine. Each year, tens of thousands of Orthodox Jewish men travel to celebrate Rosh Hashanah at the grave of Rabbi Nachman of Breslov (which Vice has called the “Hasidic Burning Man”). Israel, London, and New York’s Bensonhurst and Rockland County communities all experienced outbreaks shortly after.

Ukraine’s domestic outbreak was the result of a faltering government that made some very bad decisions. Rather than use less expensive sources for vaccines, like those made by companies in India, the administration selected a European source of medicine that the Ukrainian government ultimately couldn’t afford. This while the eastern border area continues to be the site of armed conflict between pro-Russian forces and the Ukrainian government, which has no surplus of good will and trust among its impoverished people.

Meanwhile, an unbridled misinformation campaign made the most of the 2008 death of a young man after he was vaccinated. In March of this year, the Red Cross was deployed to the country, providing vital vaccination labor and resources. But the question of how to combat the rampant misinformation that surrounds vaccinations continues to flummox experts around the world.

Quack Attack

Anti-vaxxers’ arguments have evolved over the years, since their reinvigoration in the late 1990s, mutating in order to survive, like the viruses they ultimately foster. The movement intensified in 1998 when an explosive and erroneous study by Andrew Wakefield, a British surgeon, appeared in the distinguished medical journal, The Lancet. The study linked the measles, mumps, and rubella (MMR) vaccine to autism. At the time, childhood autism was just coming to light and the study struck fear in the hearts of parents who dreaded this unstudied, emergent disorder. Wakefield’s work was almost immediately and resoundingly debunked by other scholars, but the powerful seeds of doubt had been sown. Skeptics, conspiracy theorists, quacks, and hucksters were joined in their denigration of vaccines by the likes of celebrities, new agers, organic warriors, soccer moms, and politicians.

Wakefield has since lost his medical license in the United Kingdom (the study was finally retracted by The Lancet twelve years later) but his vehement denunciation of vaccines continues, fostered by the strength and vitality of a movement he helped found. No one was surprised when Wakefield met with presidential candidate Donald Trump, who had tweeted about the connection between vaccines and “AUTISM! Many such cases!” Then, in January 2017, during the early chaotic days of the Trump administration, the medical news site STAT reported Robert F. Kennedy’s announcement that he would chair a new federal panel on vaccines. The panel never came to fruition.

So now with systemic failures and poverty helping measles to spread in other countries, we have a range of resistances in the United States that add to the threat. It can be parents’ reticence to see their child stabbed with a vaccinating needle; it can be doubt sown by credulous celebrities (such as Kennedy, or Jenny McCarthy, Jessica Biel, Alicia Silverstone, Charlie Sheen, Juliette Lewis . . . ); it can be distrust in government or stories of failed vaccinations, true or untrue. As much as the anti-vaxxer movement is fueled by a type of deluded exceptionalism, it is also constructed from mass misinformation. Once you’re in, everything confirms your own decision to not vaccinate your children; everybody else is on their own. It’s hard not to sympathize with this kind of dogmatic opposition, except that it’s based on lies and faked science and a whole lot of ephemeral-but-emotionally-compelling bunk. And it kills people. All over the world.

Bioethicist Arthur Caplan has observed that the movement continues to find new and innovative reasons to oppose vaccines. As the connection to autism has slowly been debunked, the health craze has picked up: the (highly monetized) demand for organic, grass-fed, unprocessed foods and accompanying reliance on the wisdom of Mother Nature. Parents are increasingly seeing vaccines as an interruption to life’s natural course and dismissing the fatality rates of measles. Others are embracing a new kind of rights language that characterizes government regulation as coercion. “‘I have a right to do what I want to do,’” Caplan said, paraphrasing a common refrain from vaccine-hesitant parents. “We see a lot of individualism in our society now.”

The Executive Stress Test

In a 2017 article for Public Books, Berkeley political theorist Wendy Brown argued that forty years of neoliberalism has reduced the inherently rich meanings of freedom to one tired and capitalistic definition: freedom from coercion. She wrote, “Neoliberalism fostered this development through a starkly market-libertarian meaning of freedom, crucially combined with a relentless attack on ‘the social’ and all that it comprises—social powers, social justice, the very idea of a society tended in common.” This narrowing of our understanding and use of freedom—particularly by the courts—has caused the rise of lawsuits aimed at protecting individual “rights,” often at the expense of social well-being and equality.

The emphasis on “freedom from coercion” was evident when New York mayor Bill de Blasio announced an emergency health order in April requiring measles vaccinations throughout parts of the city. Vaccine skeptics began collecting signatures on court affidavits in preparation for a lawsuit. “I am a religious Jew, whose religious convictions are being blatantly violated by the vaccine Diktats, which are a clear violation of the Nuremberg Code, which forbids forcing medical procedures on anyone without their fully informed consent,” one affidavit read. “Childhood diseases, like measles and chickenpox, unlike smallpox and ebola, are not a legitimate public health menace, and do not justify an emergency declaration.”

Like being forced to make a cake for a gay couple despite your religious opposition to same-sex marriage, like a health care law that requires your privately held company to provide insurance that covers abortion, vaccination mandates—particularly those without religious exemptions—are being disparaged as a violation of First Amendment rights. Human and biological needs for the future, the rights of others, the rights of the disadvantaged—and let’s be honest, the rights of anyone not represented by the hyper-conservative, minority-ruling political party—be damned.

Still, New York was able to pass a bill that eliminated religious exemptions in June, joining California, Arizona, West Virginia, Mississippi, and Maine. And the increasingly volatile issue, as framed by the New York Times’ Jesse McKinley, is “pitting parental prerogative and public health.”

Virulent Hatreds

New York rabbis believe that the controversy surrounding the measles outbreak is increasing anti-Semitic incidents. In April, an MTA driver was reported for allegedly trying to stop a Hasidic woman in Brooklyn from boarding his bus. When he eventually did allow her to board, he yelled “measles,” and told her to move to the back of the bus, according to the New York Times. With any outbreak, fear becomes palpable in a society, and minority groups often become the focus of that fear and anxiety. “Chasidim are held to be at fault for not vaccinating just as African Americans are blamed for crack cocaine, poor white people for opioid addiction, and women for chronic pain,” Zackary Berger, a doctor, recently wrote at the medical website KevinMD. “It is always easier to blame the patient, or the affected population, than correct the underlying issues.”

But correcting those underlying issues, in Brooklyn, Santa Barbara, Uman, or elsewhere, is proving to be more challenging than simply pointing out the scientific facts. “Whether a vaccine is better described as a well-tested tool for preventing disease or a foreign incursion into the body may hang on whether you’re comparing it to medical interventions or to causes of disease and disability,” Gregory E. Kaebnick and Michael Gusmano wrote at Slate in April. Science, they argue, is not enough to change minds, particularly when those minds are reinforced by members of their immediate community.

What doesn’t kill you makes you stronger. That’s the basic observation that led to the very first inoculations against viral disease. Perhaps as early as 1000 B.C., the Chinese were drying and grinding smallpox scabs into a powder that was then blown into the noses of patients. Turkish practitioners later adopted similar practices, some rubbing the pus from smallpox wounds into a cut on patients’ bodies. The practice was also used in India and Africa. If your patient survived a mild form of induced smallpox, early practitioners learned, their chances of contracting the disease again were significantly diminished.

What doesn’t kill you makes you stronger. That’s the basic observation that led to the very first inoculations against viral disease.

It was from his West African slave, Onesimus, that Boston’s Cotton Mather probably learned about inoculation. By the time an infected passenger got off the HMS Seahorse in Boston Harbor in 1721, carrying the germs of what would be the most deadly smallpox episode of the colonial era, Mather had managed to win the support and collaboration of a doctor named Zabdiel Boylston. Though other Massachusetts doctors had prevented a city-wide inoculation effort, Mather and Boylston took up their own campaign. Throughout the epidemic, they recorded only a 2 percent mortality rate among those who had been inoculated. Stories of their success spread throughout the colonies and into Europe, where royal family members were soon using the treatment to protect their children. By 1777, George Washington was inoculating his troops.

Almost twenty years after Mather’s work with Boylston to contain smallpox, a British doctor named Edward Jenner discovered that a milkmaid, Sarah Nelms, who had contracted cowpox, was immune to smallpox. He developed a method of treating patients with the cowpox virus to protect them against smallpox: vaccination comes from the Latin word for cow, vacca. Still, convincing his peers of the treatment’s efficacy was no easy thing. When he submitted a paper to the Royal Academy of Science the following year documenting his discovery, the paper was rejected. But as we all know, Jenner’s vaccination was eventually adopted by the global medical community. Smallpox was declared to be eradicated in 1980. It remains the only infectious disease to have been eliminated from the human population by vaccine.

Ann Neumann is the author of The Good Death: An Exploration of Dying in America.